Provider Demographics
NPI:1265758460
Name:JOHN A CROCKETT MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JOHN A CROCKETT MD A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:F
Authorized Official - Last Name:STEMMLER
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:619-258-6200
Mailing Address - Street 1:210 LA COLINA DR
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-1816
Mailing Address - Country:US
Mailing Address - Phone:925-519-2866
Mailing Address - Fax:925-692-5522
Practice Address - Street 1:240 LA CASA VIA STE 100
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-4863
Practice Address - Country:US
Practice Address - Phone:925-519-2866
Practice Address - Fax:925-692-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG230620207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1134221021Medicaid